CMS/EIP Fiscal Report Center: 02
Services beginning 10/01/2017 ending 12/31/2017 Date of Report:02/03/2018 Page: 1
List order: No List
Eligibility Filter:Program Patients
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 755 627.750000 23226.7500 37.0000
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 326 466.750000 0.0000 0.0000
TCM-T1017TL-TARGETED CASE MANAGEMENT 686 1083.500000 40053.5000 36.9668
Subtotal (Total Children Is Unduplicated) 833 2178.000000 63280.2500 29.0543
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Screening, Eval, and Assessment,Class #02
AUDE-92552-PURE TONE AUDIOMETRY -AIR ONLY 1 1.000000 17.9200 17.9200
AUDE-92553-PURE TONE AUDIOMETRY AIR & BONE 1 1.000000 21.3500 21.3500
AUDE-92555-SPEECH AUD THRESHOLD (DETECTION) 2 2.000000 25.2200 12.6100
AUDE-92567-TYPMANOMETRY (IMPEDANCE TESTING) 2 2.000000 16.5200 8.2600
AUDE-92579-VISUAL REINFORCEMENT AUDIOMETRY 2 2.000000 50.6200 25.3100
AUDE-92587-OTOACOUSTIC EMISSIONS (LIMITED) 1 1.000000 18.5500 18.5500
AUDE-V5090-DISPENSING FEE PER HEARING AID 1 1.000000 115.0000 115.0000
EXIT-EXIT-EXIT ASSESSMENT 40 48.500000 2425.0000 50.0000
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 1 2.000000 150.0000 75.0000
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 1 2.000000 150.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 1 2.000000 150.0000 75.0000
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 3 6.000000 333.0000 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 64 115.000000 8625.0000 75.0000
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 59 112.500000 8437.5000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 75 129.000000 7159.5000 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 30 58.000000 4350.0000 75.0000
OCTH-97165-OT EVAL LOW COMPLEXITY 3 3.000000 153.1500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 2 2.000000 74.9100 37.4550
PSTH-97163-PT EVAL HIGH COMPLEXITY 1 1.000000 14.4300 14.4300
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 3 3.000000 153.1500 51.0500
Subtotal (Total Children Is Unduplicated) 195 494.000000 32440.8200 65.6697
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EI Services,Class #03
ASST-ASST-ASSISTIVE TECHNOLOGY 6 8.000000 13467.4000 1683.4250
COIFF-COIFF-IFSP CONSULT, PROF, FACE TO FACE 41 50.500000 2525.0000 50.0000
CONIF-CONIF-CONSULT, ITDS FACE TO FACE 74 53.750000 2687.5000 50.0000
CONIP-CONIP-CONSULT, ITDS PHONE 9 4.500000 112.5000 25.0000
CONOF-CONOF-CONSULT, OT, FACE TO FACE 29 21.500000 1075.0000 50.0000
CONPF-CONPF-CONSULT, PT, FACE TO FACE 1 0.500000 25.0000 50.0000
CONSF-CONSF-CONSULT, SLP, FACE TO FACE 48 36.750000 1837.5000 50.0000
CONSP-CONSP-CONSULT, SLP, PHONE 9 4.000000 100.0000 25.0000
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 155 733.750000 36687.5000 50.0000
INTR-T1013-INTERPRETER 28 64.250000 3212.5000 50.0000
NESF-99600-NATURAL ENVIRONMENT SUPPORT FEE 422 2904.000000 29040.0000 10.0000
OCCT-97530-OT SESSION BY LICENSED OT 30 116.750000 8340.6200 71.4400
PHY-97110-PT SESSION BY LICENSED PT 28 107.500000 5538.0100 51.5164
SENS-V5060-BEHIND EAR HEARING AID
1 1.000000 228.0000 228.0000
SENS-V5264-EARMOLD 1 1.000000 18.0000 18.0000
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 53 359.500000 25629.0800 71.2909
TRAV-TRAVS-Travel by mile 318 19000.00000 8456.9300 0.4451
Subtotal (Total Children Is Unduplicated) 641 23467.25000 138980.5400 5.9223
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Total 26139.250000 234701.6100 8.9789
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Number of Children (Unduplicated) With at Least One Service 987
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Center 02
Flag Claims Units Chgs Paid
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R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 0 0.000000 0.0000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 4656 11907.750000 125662.4600 125308.8600
1 1.000000 71.4400 51.0500
Other 4816 14230.500000 108967.7100 0.0000
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Total 9473 26139.250000 234701.6100 125359.9100